North Carolina Home Health Policy and Procedure Manual
For North Carolina home health agencies: home care agencies licensed by the Division of Health Service Regulation (DHSR) that are Medicare-certified and hold a certificate of need. The manual has 57 policies and 47 forms, written to 10A NCAC 13J, the home care licensure rules, the home health Conditions of Participation (42 CFR Part 484) and NC Medicaid Clinical Coverage Policy 3A. Each policy opens with a plain-English summary and names the rule it follows, and every one is filled in with your agency's details. You get Word and PDF files to keep, and your staff sign off on their phones.
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North Carolina · Home health
57 policies written to the North Carolina rules, with 47 forms. Every one is filled in with your agency's details.
- A plain-English summary first
- The rule each policy follows
- Word and PDF downloads, yours to keep
- Policies
- 57
- Forms
- 47
- Categories
- 13
- Policy Pack · required
- $950one-timeIncludes 90 days in the portal with Premium. To keep it open after that, Premium is $99 a month or $990 a year.
Read before you buy
3 free sample policies, shown in full for a sample agency.
NC-HH-CMP-01Free sample
Client rights
Complaints and Grievances
Requires the Agency to investigate every complaint made by a patient or family within 72 hours, as G.S. 131E-144.6(b) requires, to document both the complaint and its resolution, to act to prevent further problems and retaliation while it investigates, and to tell every patient in writing how to complain to the Agency and to the Division of Health Service Regulation Complaint Intake Unit.
Read the full policy NC-HH-SG-01Free sample SafeguardingAbuse, Neglect, and Exploitation of Disabled Adults: Recognition and Reporting to the County Department of Social Services
Requires every staff member who has reasonable cause to believe that a disabled adult needs protective services because of abuse, neglect (including self-neglect) or exploitation to report it to the county department of social services where the adult lives or is present, as G.S. 108A-102 requires of any person. North Carolina has no statewide adult protective services hotline. The Agency’s standard is to report immediately and before the end of the shift, to call 911 first if anyone is in danger, and also to report allegations against Agency staff under Policy NC-HH-SG-02.
Read the full policy NC-HH-IC-01Free sample Infection controlInfection Prevention and Control and Communicable Disease Reporting
Sets up the Agency’s infection prevention and control program for every patient: the written infection control policy and designated staff member North Carolina requires of a home care agency that performs invasive procedures, a yearly risk assessment with employee risk categories, standard and transmission-based precautions, cleaning, disinfection and maintenance of equipment, surveillance of infections built into QAPI, reporting of suspected reportable diseases with the patient’s physician and the local health department, control measures and outbreaks, staff health, and education for staff, patients and caregivers.
Read the full policy
North Carolina rules
What North Carolina's rules ask your policies to cover
- Plan of care reviews. The plan of care is reviewed at least every 60 days under the federal rules, and every 90 days by the health care practitioner under North Carolina's rule. 42 CFR §484.60(c)(1); 10A NCAC 13J .1202(a)
- Aide supervision. For patients who also get skilled care, a supervisory assessment of the aide at least every 14 days. For patients who get only aide services, an on-site registered nurse visit every 60 days. 42 CFR §484.80(h)
- Notice before services change. At least 48 hours' notice before services are reduced or ended, unless the patient agrees, there is danger to the patient or a staff member, or the physician ends services. 10A NCAC 13J .1101(7)
- Complaints. The agency investigates complaints from a patient or the patient's family within 72 hours, and documents each complaint and how it was resolved. G.S. 131E-144.6(b)
- Allegations against staff. Every allegation against unlicensed staff, including an injury of unknown source, is reported to the Department within 24 hours of the agency becoming aware, with the investigation results within five working days. 10A NCAC 13O .0102; G.S. 131E-256(g)
- Verbal orders. Countersigned by the physician within 60 days of the date of the order. 10A NCAC 13J .1302(d)
Questions a surveyor may ask
Every policy lists questions a surveyor may ask about it, so your staff can practice the answers. A few from this manual:
How do you make sure the plan is reviewed at least every 60 days and every 90 days?NC-HH-CP-01Plan of Care: Development, 90-Day Review, Physician Notification, and Patient Instructions
When was the last aide supervisory visit for this patient? Was it on site? Who made it?NC-HH-AID-02Home Health Aide Assignment, Care Instructions, and Supervisory Visits
When may you discharge without 48 hours’ notice?NC-HH-DC-02Reduction, Termination, Transfer, and Discharge Notice, Including Discharge for Cause
An aide was accused of taking money from a patient on Friday evening. When was the report due, and what did you do with the aide in the meantime?NC-HH-SG-02Allegations Against Staff: Health Care Personnel Registry Reports and Agency Investigations
How would you know which patients need help first if a hurricane is coming?NC-HH-EP-01Emergency Preparedness and Management of Emergency Care Situations in the Home
The full pack
Browse all 57 policies
Search by title, policy number or rule. Open any policy to see its summary, the rules it follows and what is inside.
All 57 policies
Client rights6
NC-HH-CMP-01Free sample
Complaints and Grievances
Requires the Agency to investigate every complaint made by a patient or family within 72 hours, as G.S. 131E-144.6(b) requires, to document both the complaint and its resolution, to act to prevent further problems and retaliation while it investigates, and to tell every patient in writing how to complain to the Agency and to the Division of Health Service Regulation Complaint Intake Unit.
G.S. 131E-144.6(b)
NC-HH-DC-02
Reduction, Termination, Transfer, and Discharge Notice, Including Discharge for Cause
Allows the Agency to transfer or discharge a patient only on the grounds 42 CFR §484.50(d) permits, and requires at least 48 hours’ advance notice to the patient or responsible party before any reduction or termination of service (North Carolina’s three exceptions only), the Medicare termination notice no later than 2 days before covered services end, notice to the physician, coordination of other care, and, for a discharge for cause, a written policy, warning, attempts to resolve the problem, contacts for other providers, and full documentation.
10A NCAC 13J .1101(7)
NC-HH-PR-01
Patient Rights and Responsibilities (Home Care Clients’ Bill of Rights)
Gives every patient, during the initial evaluation visit and before care starts, a written notice of the North Carolina Home Care Clients’ Bill of Rights and the federal home health patient rights, the patient’s responsibilities, the Agency’s transfer and discharge policies, and the contacts for complaints (the administrator, the Agency, and the Division of Health Service Regulation hotline), with a signed receipt kept in the record, an oral explanation in the patient’s own language, and a copy to a patient-selected representative within 4 business days.
G.S. 131E-144.3
NC-HH-PR-02
Advance Directives, Portable Do-Not-Resuscitate Orders, and MOST
Gives every adult patient written information about the right to accept or refuse treatment and to make advance directives under North Carolina law, before care is provided; records in a prominent place whether the patient has an advance directive; puts that information in the plan of care; never conditions care on whether a patient has one; and tells staff how to act on a valid portable do-not-resuscitate order or Medical Orders for Scope of Treatment (MOST) form in an emergency.
42 CFR §489.102
NC-HH-PR-03
Service Agreement, Consent, Statement of Services and Charges, and Notice About Record Review
Requires a signed service agreement for every patient before care begins, recording the patient’s informed consent to the planned services, a written statement of the services and the charges the patient may have to pay (with oral explanation), the process for acceptance, continuance and eligibility, the right to refuse, consent to share information with other providers, and the patient’s right to be told in writing before the Division of Health Service Regulation reviews the record and to object.
G.S. 131E-144.3
NC-HH-PR-04
Language Access, Accessibility, and Nondiscrimination
Makes sure patients with limited English proficiency and patients with disabilities can understand and take part in their care: free qualified interpreters and translated documents, free auxiliary aids and services, plain language, accessible notices, no use of children or untrained adults as interpreters except in an emergency, and no discrimination on any protected basis.
42 CFR §484.50(f)
Service delivery10
NC-HH-ADM-01
Acceptance of Patients, Referral Intake, and Public Information About Services
Sets the written acceptance policy North Carolina and Medicare require: every referral is screened the same way against the patient’s needs and the Agency’s staffing, skills, caseload and case mix, service area, the home setting and caregiver support; the referral source is told when a requested service cannot start in the time it asked for; every non-admission is logged with its reason; patients the Agency cannot serve are referred on; and the public information about services and their limits is kept accurate and reviewed at least once a year.
10A NCAC 13J .1101
NC-HH-ADM-02
Start of Care, Initial Assessment Visit, and Referral-Source Notification
Requires a registered nurse (or, for a therapy-only patient, the therapist) to make the initial assessment visit within 48 hours of referral or of the patient’s return home, or on the ordered start of care date, and within the Agency’s own shorter start-of-care time frame; sets what happens at that visit (rights, consent, eligibility, immediate needs, safety); allows care to start on a verbal order; and requires the referral source and physician to be told whenever the time frame cannot be met.
42 CFR §484.55(a)
NC-HH-ADM-03
Eligibility, Certification, Face-to-Face Encounter, Homebound Status, and NC Medicaid Coverage
Sets how the Agency confirms, before and during care, that each patient is eligible under the payer’s rules: for Medicare, the physician or allowed practitioner certification, the face-to-face encounter (90 days before to 30 days after the start of care), homebound status, need for skilled services, a plan of care, and recertification at least every 60 days; for NC Medicaid, the attending physician’s order and certification, the face-to-face attestation, documentation of why services must be given at home, eligibility checks at each service, prior approval where required, and coordination rules.
42 CFR §424.22
NC-HH-ASM-01
Comprehensive Assessment and Reassessment
Requires a patient-specific comprehensive assessment, completed by a registered nurse (or the therapist for a therapy-only patient) no later than 5 calendar days after the start of care, covering the content in 42 CFR §484.55(c) including a drug regimen review, OASIS items, and the patient’s individual emergency plan; updated in the last 5 days of every 60 days, within 48 hours of return home from a hospital stay of 24 hours or more, on a major change, and at discharge; and the 90-day North Carolina review of condition, progress and response by the health care practitioner.
42 CFR §484.55
NC-HH-ASM-02
OASIS Data Collection, Accuracy, and Transmission
Makes sure OASIS data are collected as part of every comprehensive assessment by the registered nurse or therapist who did the assessment, reflect the patient accurately, are reviewed before they are locked, and are encoded and transmitted to CMS within 30 days of completing the assessment, through software and connections that meet CMS standards, with patient-identifiable OASIS data kept confidential and never released to the public.
42 CFR §484.45
NC-HH-CC-01
Coordination of Services, Case Conferences, and Referral to Community Agencies
Makes sure every patient’s care is coordinated: communication with all ordering practitioners, integration of all orders and of every discipline and contractor, case conferences, involvement and education of the patient and caregivers, documented coordination whenever a patient receives more than one service, the NC Medicaid coordination rules (private duty nursing, home infusion, nutrition therapy, hospice, CAP), and referral to and from community agencies.
42 CFR §484.60(d)
NC-HH-CC-02
On-Call Services, After-Hours Care, and Supervisor Availability
Provides on-call nursing 24 hours a day, seven days a week, keeps every current and past on-call schedule for at least one year for the Department, keeps a registered nurse available (and able to go on site) whenever home health aides are working, keeps the administrator or a pre-designated person and a clinical manager available during all operating hours, tells every patient how to reach the on-call service and a supervisor, and logs and follows up every after-hours call.
10A NCAC 13J .1102(c)
NC-HH-CP-01
Plan of Care: Development, 90-Day Review, Physician Notification, and Patient Instructions
Requires an individualized written plan of care for every patient, developed with the patient from the comprehensive assessment, signed by the physician or allowed practitioner, containing everything North Carolina and Medicare list; reviewed and revised by the practitioner and the Agency at least every 60 days (which also meets the North Carolina 90-day review by the health care practitioner) and whenever the patient’s condition requires; with prompt notice to the practitioner of changes, communication of every revision, advance notice to the patient of changes, and written visit, medication and treatment instructions with the clinical manager’s contact details.
10A NCAC 13J .1202
NC-HH-CS-01
Scope of Services, Service Categories on the License, and Services Offered
Describes the home care services the Agency is licensed for and offers, where and how each is given (directly or under arrangement), the federal rule that skilled nursing and at least one other therapeutic service be made available with one given directly, how services are added, stopped or changed with written notice to the Division of Health Service Regulation, and how accurate public information about services and their limits is kept current.
10A NCAC 13J .1001(a)(1)
NC-HH-DC-01
Discharge Planning, Transfer, and Discharge and Transfer Summaries
Requires discharge planning from the start of care, help in choosing a post-acute provider using quality and resource-use data, a discharge assessment, and a discharge summary that gives an overall summary of services and the date and reason for discharge, sent to the follow-up practitioner within 5 business days; a transfer summary sent within 2 business days of a planned transfer or of learning of an unplanned one; and documentation of the date and reason whenever one service ends while others continue.
42 CFR §484.58
Clinical tasks10
NC-HH-AID-01
Home Health Aide Qualifications, Training, Competency Evaluation, and Registry Listing
Allows only qualified home health aides to give care: each aide has completed training and a competency evaluation meeting 42 CFR §484.80 and is listed on the North Carolina Nurse Aide I Registry (or as a Nurse Aide II on both registries), has not had a 24-month break from paid aide work, has shown each assigned task to a registered nurse, and completes at least 12 hours of in-service training every 12 months. Sets the content of any training or competency evaluation program the Agency runs.
42 CFR §484.80
NC-HH-AID-02
Home Health Aide Assignment, Care Instructions, and Supervisory Visits
Sets how home health aides are assigned to patients and given written care instructions, what aides may and may not do, and how a registered nurse or therapist supervises them: every 14 days for patients receiving skilled services, every 60 days in person for aide-only patients, observation of each aide while giving care, and the North Carolina 90-day and annual visits, which the Agency meets through the federal schedule. Covers documentation and corrective action.
42 CFR §484.80(h)
NC-HH-CS-02
Nursing Services: Registered Nurse and Licensed Practical Nurse Duties
Requires all nursing to be given by or under the supervision of a registered nurse under the Nursing Practice Act; sets out what the registered nurse and the licensed practical nurse each do under 10A NCAC 13J .1102 and the Board of Nursing rules; sets the Agency’s method and frequency for supervising licensed practical nurses; and limits delegation to unlicensed staff to tasks that meet the Board’s criteria.
10A NCAC 13J .1102
NC-HH-CS-03
Therapy and Medical Social Work Services
Sets out what physical therapy, occupational therapy, speech-language pathology and medical social work must include under 10A NCAC 13J .1103 to .1106, requires the licensed therapist to perform initial and discharge assessments and plan of care updates and to be accessible at all times a therapy assistant is treating, sets the Agency’s supervision of therapy and social work assistants, and applies the federal qualification and supervision rules.
10A NCAC 13J .1103
NC-HH-CS-04
Clinical Respiratory Services and Home Medical Equipment and Supplies
Applies when the Agency provides clinical respiratory or ventilation services, or supplies medical equipment and supplies with its home care services: respiratory services are given by or under a respiratory therapist or a registered nurse with demonstrated competency under a physician-signed plan of care, with 24-hour on-call emergency response; equipment is set up, cleaned, maintained, tracked, recalled and backed up for power failure as 10A NCAC 13J .1112 requires; and NC Medicaid supply rules are followed. Also covers safety checks on equipment other suppliers provide.
10A NCAC 13J .1109
NC-HH-CS-05
Laboratory Services and Waived Testing
Allows Agency staff to perform laboratory tests only under a current CLIA certificate (normally a certificate of waiver, limited to waived tests done exactly as the manufacturer directs), never to substitute Agency equipment for a patient’s own self-testing device, and to send specimens only to certified laboratories. Sets ordering, collection, transport, result reporting and certificate renewal.
42 CFR §484.100(c)
NC-HH-CS-06
Death in the Home and Pronouncement of Death
Sets what staff do when a patient dies or is found without signs of life at home: follow a valid portable do-not-resuscitate order or MOST form; otherwise call 911 and begin CPR if trained; never disturb the body where the death may fall under the medical examiner statute; notify the physician who will certify the cause of death, the supervising nurse and the family’s funeral home; share infection precautions; and record everything. Plans expected deaths of patients not in hospice in advance.
10A NCAC 13J .1001(a)(5)
NC-HH-MED-01
Medication Administration, Drug Regimen Review, and Vaccines
Sets who may administer medications and who may only assist with self-administration, the staff accountability North Carolina requires for every drug or treatment the Agency gives, the drug regimen review in every comprehensive assessment, the written medication schedule for the patient, the influenza and pneumococcal vaccine protocol, and how medication problems and errors are reported.
10A NCAC 13J .1301
NC-HH-MED-02
Infusion Nursing and Pharmacy Services
Applies when the Agency’s license includes infusion nursing services: infusion is given by or under the supervision of a registered nurse trained in infusion, under a physician-signed plan of care; on-call infusion nursing is available 24 hours a day, seven days a week; infusion pharmacy services, if provided or contracted, are governed by written scope and run around the clock under North Carolina pharmacy law; and NC Medicaid coordination with Home Infusion Therapy providers is followed.
10A NCAC 13J .1108
NC-HH-ORD-01
Physician and Practitioner Orders, Verbal Orders, and Countersignature
Requires every drug, treatment and service to be given only on the order of a physician or other authorized practitioner; sets who may take a verbal order, how it is read back, recorded, signed, dated and timed; requires countersignature within the Agency’s time frame of 14 days, never more than the 60 days North Carolina allows and always before a Medicare claim is billed; and sets how orders are tracked, clarified and kept.
10A NCAC 13J .1302
Safeguarding3
NC-HH-SG-01Free sample
Abuse, Neglect, and Exploitation of Disabled Adults: Recognition and Reporting to the County Department of Social Services
Requires every staff member who has reasonable cause to believe that a disabled adult needs protective services because of abuse, neglect (including self-neglect) or exploitation to report it to the county department of social services where the adult lives or is present, as G.S. 108A-102 requires of any person. North Carolina has no statewide adult protective services hotline. The Agency’s standard is to report immediately and before the end of the shift, to call 911 first if anyone is in danger, and also to report allegations against Agency staff under Policy NC-HH-SG-02.
G.S. 108A-102
NC-HH-SG-02
Allegations Against Staff: Health Care Personnel Registry Reports and Agency Investigations
Requires the Agency to report every allegation of abuse, neglect, misappropriation of property, drug diversion or fraud against an unlicensed staff member with direct access to patients, including injuries of unknown source, to Health Care Personnel Investigations at the Division of Health Service Regulation within 24 hours of becoming aware of it, to protect patients while it investigates, and to send the results of its investigation within five working days of the first report.
10A NCAC 13O .0102
NC-HH-SG-03
Child Abuse, Neglect, and Dependency Reporting
Requires every staff member who has cause to suspect that any child is abused, neglected or dependent, or has died as the result of maltreatment, to report it to the county department of social services where the child lives or is found, and, when the child has been the victim of a violent offense, a sexual offense or misdemeanor child abuse, also to local law enforcement, immediately. The duty applies to every child staff see in their work, not only to patients.
G.S. 7B-301
Infection control2
NC-HH-IC-01Free sample
Infection Prevention and Control and Communicable Disease Reporting
Sets up the Agency’s infection prevention and control program for every patient: the written infection control policy and designated staff member North Carolina requires of a home care agency that performs invasive procedures, a yearly risk assessment with employee risk categories, standard and transmission-based precautions, cleaning, disinfection and maintenance of equipment, surveillance of infections built into QAPI, reporting of suspected reportable diseases with the patient’s physician and the local health department, control measures and outbreaks, staff health, and education for staff, patients and caregivers.
42 CFR §484.70
NC-HH-IC-02
Bloodborne Pathogens Exposure Control Plan, Sharps, and Medical Waste
The Agency’s written exposure control plan under the OSHA bloodborne pathogens standard, which North Carolina has adopted: exposure determination, universal precautions and safer sharps, protective equipment at no cost, hepatitis B vaccination within 10 working days of initial assignment or a signed declination, immediate confidential post-exposure evaluation that follows North Carolina’s source-testing rules, training at assignment and every year, the sharps injury log and record retention, and North Carolina’s medical waste rules for sharps containers and regulated medical waste.
29 CFR §1910.1030
Emergency preparedness1
Records2
NC-HH-REC-01
Service Records: Content, Entries, Completion and Return, and Retention
Sets out what every patient’s service record contains, how entries are dated, authenticated and corrected, the Agency’s time frame for completing and returning service records, where originals are kept, and how long records are kept: at least six years after discharge for every patient (the NC Medicaid period, which is longer than the five years in 10A NCAC 13J and 42 CFR §484.110), longer for minors, and seven years from the date of service for orders, certifications and claims.
10A NCAC 13J .1401
NC-HH-REC-02
Patient Access to Records, Copies, Release of Information, and Record Removal
Gives every patient a free copy of the clinical record at the next home visit or within 4 business days, whichever comes first, sets out how other access requests, authorizations, subpoenas and requests from the Division of Health Service Regulation are handled, and requires a sign-out log and return within five working days for any original record removed from the licensed premises for an evaluation.
42 CFR §484.110(e)
Privacy3
NC-HH-PRV-01
HIPAA Privacy and Patient and Employee Confidentiality
Sets out how the Agency protects the confidentiality of patient and employee information, as 10A NCAC 13J .1001(a)(10) and G.S. 131E-144.3(5) require, and how it meets the HIPAA Privacy Rule: the Privacy Official, the Notice of Privacy Practices given at the start of care, when information may be shared without the patient’s authorization (including reports to the county department of social services and the Health Care Personnel Registry), the patient’s privacy rights and their time limits, and OASIS confidentiality.
45 CFR Part 164 Subpart E
NC-HH-PRV-02
HIPAA Security
Sets out the administrative, physical and technical safeguards the Agency uses to protect electronic patient and employee information under the HIPAA Security Rule, with particular rules for the laptops, tablets and phones clinicians carry into homes (including electronic visit verification apps), OASIS transmission, security incidents, backup and contingency planning, business associates and disposal of devices.
45 CFR §164.308
NC-HH-PRV-03
Breach Notification Under HIPAA and North Carolina Law
Requires every suspected loss, theft or wrongful disclosure of patient or employee information to be reported to the Privacy Official the same day, assessed in writing, and notified as the law requires: under HIPAA, to each affected patient no later than 60 calendar days after discovery, to HHS, and to the media for large breaches; and under North Carolina’s Identity Theft Protection Act, to each affected person without unreasonable delay when unencrypted personal information such as a Social Security or account number is involved, with notice to the Attorney General’s Consumer Protection Division.
45 CFR §164.404
Human resources5
NC-HH-HR-01
Personnel Policies, Job Descriptions, Qualifications, Orientation, In-Service Education, and Performance Evaluation
Requires a written job description with qualifications and responsibilities for every position, sets the qualifications for each clinical discipline, and sets out orientation, competency verification by demonstration, in-service education (the number of hours the North Carolina rules leave to agency policy), and performance evaluation at least annually.
10A NCAC 13J .1003(d)
NC-HH-HR-02
Personnel Records, Tuberculosis Screening, and Hepatitis B Documentation
Lists what every personnel record must contain under North Carolina rules, requires a baseline tuberculosis skin test (or symptom verification) before hands-on care and annual symptom verification for previously positive staff, requires documentation of hepatitis B immunization or declination, and keeps personnel records at least one year after employment ends.
10A NCAC 13J .1003(f)
NC-HH-HR-03
Criminal History Record Checks
Requires a conditional offer of employment and a criminal history record check for every applicant who would enter patients’ homes, with the request submitted within five business days of the conditional offer, a national fingerprint check for applicants who have lived in North Carolina for less than five years, an individual review of any record against the factors the statute lists, and strict confidentiality of results.
G.S. 131E-265
NC-HH-HR-04
Health Care Personnel Registry, Nurse Aide Registry, and License Verification
Requires the Agency to check the North Carolina Health Care Personnel Registry before hiring anyone and to record each check, bars hiring anyone with a substantiated Registry finding, requires home health aides to be listed on the Nurse Aide Registry, and requires every license, certification and registration to be verified at hire and before it expires.
G.S. 131E-256
NC-HH-HR-05
Staff Safety in the Home and Workplace Violence Prevention
Protects staff who work alone in patients’ homes and on the road: safety screening at referral and a home safety assessment at the start of care, risk levels with written safety plans, precautions before and during visits, the right to leave an unsafe home once a supervisor is told so the patient is not left in danger, handling of threats and harassment, animals, home hazards, driving and safe patient handling, and reporting, support and review after an incident, including the N.C. Department of Labor reporting times for serious injuries.
29 U.S.C. §654(a)(1)
Governance6
NC-HH-GOV-01
Governing Body, Written Policies, Organizational Chart, and Lines of Authority
Names the governing body as the person or group with legal authority for the Agency, lists the written policies North Carolina requires every home care agency to establish and implement, and shows where each one is found in this manual. Requires a written organizational chart showing lines of authority down to the patient care level, disclosure of ownership and management, and no delegation of administrative or supervisory functions to another organization.
10A NCAC 13J .1001(a)
NC-HH-GOV-02
Agency Director, Order of Authority, Service Supervisors, and Clinical Manager
Sets the qualifications, authority and duties of the agency director (the administrator), the written order of authority when the director is absent, the supervisor designated for each home care service, and the supervising nurse who is also the clinical manager. Requires written notice to the Division of Health Service Regulation within five working days if the agency director position becomes vacant.
10A NCAC 13J .1001(b)
NC-HH-GOV-03
Licensure, Inspections, Plans of Correction, Accreditation, and Notices to the Division of Health Service Regulation
Explains how the Agency keeps its North Carolina home care license, posts it, renews it before it expires at midnight on December 31, and gives the Division of Health Service Regulation the written notices the rules require. Sets out how staff cooperate with unannounced inspections, file a plan of correction within 10 working days, report accreditation results within 30 days, and tell patients within 10 days of any action against the license.
10A NCAC 13J .0903
NC-HH-GOV-04
Certificate of Need, Geographic Service Area, Licensed Premises, and Branch Offices
Records the Agency’s certificate of need and license for each site that provides home health services, defines in writing the geographic area served for each service, limits in-home aide services to the area the rules allow, and sets out the notices required before expanding the service area or adding a premises or branch.
G.S. 131E-176(16)
NC-HH-GOV-05
Contracts and Services Under Arrangement
Requires a written agreement, signed by both parties and containing the ten items North Carolina lists, for every service the Agency provides through another agency or individual. Keeps the Agency responsible for contracted care, requires contracted staff to meet the same requirements as Agency staff, and requires each agreement to be reviewed every year.
10A NCAC 13J .1111
NC-HH-GOV-06
Change of Ownership, Agency Closure, and Custody of Records
Sets out the steps for a change of ownership or name and for closing the Agency or a service: written notice to the Division of Health Service Regulation at least 30 days before a change of ownership or name, Medicare enrollment filings, safe transfer of every patient with at least 48 hours notice, and written notice to the Department of where records will be stored for the full retention period.
10A NCAC 13J .0903(f)
Quality3
NC-HH-QA-01
Annual Program Evaluation and 90-Day Client Record Review
Sets out the two evaluations 10A NCAC 13J .1004 requires: a comprehensive evaluation of the Agency’s total operation every year, covering policies, administration and the six kinds of data the rule lists, and an evaluation of patient records every 90 days using a representative sample of active and closed records of every service, direct and under contract. Both are documented with the evaluators’ names and qualifications, the criteria and methods, and the actions taken, and both feed the quality program.
10A NCAC 13J .1004
NC-HH-QA-02
Quality Assessment and Performance Improvement (QAPI)
Establishes the Agency’s data-driven, agency-wide quality assessment and performance improvement (QAPI) program under 42 CFR §484.65, which NC Medicaid also requires: the indicators the Agency tracks, including OASIS outcomes, emergent care use, hospital admissions and adverse events; the governing body’s approval of data collection; immediate correction of problems that threaten patient safety; performance improvement projects; and how the annual evaluation and 90-day record reviews required by 10A NCAC 13J .1004 feed the program.
42 CFR §484.65
NC-HH-QA-03
Incident Reporting, Investigation, and Adverse Events
Requires staff to report every incident (a fall, medication error, injury, equipment failure, unexpected death, missed visit that caused harm, allegation against staff, or anything else that harmed or could have harmed a patient) to a supervisor at once and in writing within 24 hours, sets out which incidents must also go to the Health Care Personnel Registry, the county department of social services or law enforcement, and how incidents are investigated and fed into the quality program.
42 CFR §484.65(c)
Business3
NC-HH-BUS-01
Annual Budget, Statistical Records, and Institutional Planning
Requires an annual budget available for inspection, the statistical records North Carolina lists (staff and full-time equivalents, patient demographics, units of service by service category, and charges and visits by payer), kept for at least three years, and the federal overall plan, annual operating budget and three-year capital expenditure plan, reviewed at least annually under the direction of the governing body.
10A NCAC 13J .1002
NC-HH-BUS-02
Charges, Billing, Claims, and Overpayments
Gives every patient a written statement of services and the charges the patient must pay before care starts, bills only for services that were ordered, provided and documented, and reports and returns any overpayment on time: for Medicare, within 60 days after it is identified unless a timely, good-faith investigation suspends the deadline.
G.S. 131E-144.3
NC-HH-BUS-03
Electronic Visit Verification for NC Medicaid Home Health Services
Requires electronic visit verification for every NC Medicaid home health visit (skilled nursing, aide, physical, occupational and speech therapy), recorded in real time through the State’s or the health plan’s EVV system or a compliant alternate system, with written notice to each patient, initial and annual staff training documented in each employee file, and manual entries kept to 15 percent or less.
NC Medicaid Clinical Coverage Policy 3A
Ethics3
NC-HH-ETH-01
Compliance Program, Exclusion Screening, and False Claims Prevention
Sets up the Agency’s compliance program: a person responsible for compliance, a code of conduct every staff member signs, training, a way to report concerns without retaliation, auditing, exclusion screening of every employee and contractor before hire and every month, and prompt correction of problems, including cooperation with NC Medicaid Program Integrity.
10A NCAC 13J .0906(a)
NC-HH-ETH-02
Referrals, Kickbacks, Patient Inducements, and Accurate Public Information
Prohibits offering, paying, asking for or accepting anything of value for patient referrals, bars gifts and waived copayments meant to attract patients, requires the governing body to review any financial relationship with a referral source, and requires the Agency’s public information about its services and limits to be accurate and reviewed at least annually.
42 U.S.C. §1320a-7b(b)
NC-HH-ETH-03
No Smoking in Patients’ Homes, Gifts, and Professional Boundaries
Prohibits staff from smoking while providing services in a patient’s home and requires the Agency to tell patients so, as North Carolina law requires, and sets the Agency’s rules on gifts, money and property, and professional boundaries so that patients are protected from exploitation and staff stay clear of allegations of misappropriation or fraud.
G.S. 131E-143
Questions
Questions about this manual
Is this the right manual for my license?
It is for North Carolina home care agencies that are Medicare-certified home health agencies. An agency that provides only in-home aide, companion or sitter services needs the North Carolina home care manual, and a hospice needs the North Carolina hospice manual.
Does North Carolina have a separate home health license?
No. A home health agency holds a home care license under 10A NCAC 13J and also needs a certificate of need (G.S. 131E-176(16)). DHSR states that each site providing home health services must have a separate certificate of need and a separate license.
We are licensed but not Medicare-certified. Does this manual fit?
It can. A licensed home care agency that is not certified is bound by 10A NCAC 13J but not by 42 CFR Part 484. The policies say so, and such an agency follows the federal parts as its own standard.
How long must we keep clinical records?
At least five years after the most recent discharge, and for a minor until three years after the 18th birthday (10A NCAC 13J .1401(f)). NC Medicaid requires six years after discharge (Clinical Coverage Policy 3A, section 7.7.2(c)).
What do the 57 policies cover?
Client rights (6), service delivery (10), clinical tasks (10), safeguarding (3), infection control (2), emergency preparedness (1), records (2), privacy (3), human resources (5), governance (6), quality (3), business (3) and ethics (3).
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